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Concerns about childcare are an often cited reason for women to leave (or never enter) male-dominated fields such as surgery – and these concerns need to be addressed. However, a recent study by Nadya Fouad suggests that childcare concerns might not be the main culprit that drives women away.

In her survey with women who held engineering degrees the author found that most women who had left engineering had not done so in order to stay at home and raise a family but had rather left the industry to work someplace else. Moreover, the reason these women cited were very similar to those that men usually cite for leaving their jobs – inhospitable work climate and a lack of opportunities for career advancement (although caregiving responsibilities were also an often cited reason).

This demonstrates once again that leaving certain occupations is not due to some inherent lack of interest among women. On the contrary, women and men are looking for quite similar things in their careers – but men might just have an easier time achieving these goals in male-dominated fields.

Gender discrimination has obvious negative effects such as keeping women from rising to leadership positions or achieving equal pay. That alone should be enough reason to address these issues but there is also evidence that demonstrates the negative impact of perceived gender discrimination on women’s motivation – one of the key ingredients to high quality work.

Sharon Foley and colleagues investigated these issues in a sample of solicitors. Not surprisingly, they found that women perceived higher levels of gender bias against women and more personal gender discrimination compared to their male counterparts. This perceived personal gender discrimination was directly linked to two important motivational outcomes. First, it predicted solicitors’ organisational committment, and second, higher perceived gender discrimination was associated with higher intentions to leave the organisation.

This study shows how important gender equality is not just for its own sake but also for keeping women motivated and committed and ultimately ensuring that their talent and expertise is not lost.

There is a lot of research on how women in male-dominated areas (e.g. management or politics) are in a somewhat “damned if you do, damned if you don’t” situation. When they present themselves in a warm and feminine way their demeanor is at odds with what the field requires (e.g. they’re not perceived as “real leaders”), but if they present themselves in a masculine, assertive way, they’re not perceived as “real women” and thus disliked. So is that also the case in surgery? A recent study by Marie Dusch and colleagues suggests that this may not necessarily be the case, at least not from the patients’ perspective.

They presented patients in a general hospital with short scenarios describing either a male or a female surgeon who presented themselves in either a feminine or masculine way. Moreover, they were described as either performing breast cancer surgery or lung cancer surgery. Somewhat surprisingly (at least to me) patients did in general not prefer male surgeons over female surgeons or masculine surgeons over feminine ones. Neither did they prefer masculine male surgeons to feminine male surgeons or feminine female surgeons to masculine female surgeons – nor the opposite. In fact, the only significant result they found was that for lung cancer surgery, masculine surgeons were seen as more competent regardless of gender.

While it is important to replicate these results before drawing strong conclusions, this study nevertheless shows that gender stereotypes in surgery may be slowly changing or at least not be as pervasive among patients as we might assume.

Quite shockingly – and we sincerely hope that this fact has changed in the 15 years since this study was conducted – almost half of the over 4000 participants report a history of sex-based harassment in a medical setting. Younger physicians were especially likely to report a history of sex-based harassment. Moreover, this was predictive of all three measures of career satisfaction: whether they felt satisfied, whether they would choose to become a physician again and whether they would like to change their specialty.

This shows that sex-based harassment is indeed a problem in the medical profession and the fact that especially younger women reported experiences of sex-based harassment in the workplace suggests that there is not necessarily a decline in sex-based harassment in medicine. The topic therefore needs to be addressed.

In order to address the under-representation of women in surgery it is important to understand what female medical students deem important in their future careers. Do they value the same things as their male counterparts and just don’t think that they can achieve those goals in a surgical career or are they actually looking for different things in their careers? A study by Nancy Baxter and colleagues suggests that the latter is the case.

They sent out a questionnaire to Canadian medical students and found that men and women named different factors as important for choosing their specialty. Women placed more importance on the availability of part-time work and parental leave as well as residency conditions, while men valued technical challenge, prestige and earning potential. As both male and female students agreed that surgeons earn a lot of money but do not have high quality family lives, it is not surprising that of the participants, men were more likely to choose surgery as the specialty they were pursuing or considering to pursue.

This study once again highlights two facts: First, it is important to make surgery a career in which family related goals can be achieved by both men and women, and second, the fact that a family and a career in surgery can be combined needs to be communicated effectively to medical students.

Research generally suggests that women receive more social support than men in terms of emotional support. However, there is also evidence that when working in male-dominated fields, women often receive less support in terms of being provided with important information or instrumental help with work tasks. A questionnaire study by Jean Wallace from the University of Calgary investigates these issues in the medical profession.

In line with previous research she finds that women receive (or at least report receiving) more emotional support than their male colleagues. However, her results do not show a gender difference in instrumental support and women actually report receiving more rather than less informational support.

This is encouraging in that it shows that women are actually well integrated in supported in the medical field. On the other hand, the results might also simply be a reflection of the fact that women are more willing to admit receiving help.

Affirmative action policies often encounter resistance even among those groups who they are designed to help. One of the reasons for this is that they are typically implemented in a “top down” fashion: Those in leadership positions within or outside of an organisation identify the need for affirmative action, decide on the policies and “force” them on the organisation.

A study by Louise McCall and colleagues addresses this issue by investigating whether a “bottom up” approach is more effective. They used focus groups to raise awareness of the under-representation of women in senior positions in academic medicine and to develop equal opportunity strategies. This approach did indeed result in a number of benefits. Not only did members of the focus groups come up with their own ideas of addressing gender inequality, but members of the faculty were also more accepting and supportive of the developed affirmative action strategies.

Lack of acceptance of affirmative action has been shown to be one of the main barriers to its effectiveness. Using focus groups or other “bottom up” approaches might be a great way of circumventing this problem and tackling inequality issues more effectively.

Last week we reported some interesting findings on the effects of different arrangement aimed at helping women in the workplace on female physician’s career motivation. Today, we would like to focus on other effects of those measures, working part-time. This measure aims to give women, especially those with kids, the opportunity to spend more time at home without abandoning their careers. However, a study by Rosemary Crompton and Clare Lyonette shows how problematic part-time work can be. In their qualitative study with accountants and physicians they find that working part-time is perceived as quite detrimental to women’s careers and the type of work they can do, especially for physicians working in hospitals. One participant notes:

“a lot of the time the part-time posts are just waiting list initiatives, you know, they need somebody to see this number of back pains or this number of people with such and such, whereas a full-time post, you’re part of a team, you’re setting up a service or doing something a bit more meaningful. So it would be difficult to get the equivalent post as a part-time person, I think.”

The authors also note that women in medicine try to avoid specialties in which part-time work might be detrimental (such as surgery) and prefer going into General Practice, which is perceived as more family friendly. On the bright side – at least for all you women in medicine – , the authors find that women in medicine fare considerably better than those in accountancy. However, whether that holds true for women in surgery, is another question.

If you are interested in guest blogging on this site some time, please get in touch. It would be great to make guest blogs a somewhat regular thing! But now, without further ado, here is what Tiffany has to say:

When I was accepted into plastic surgery training back in my mid-20’s, I was the only female plastic surgery trainee in the state. There was only one female plastic surgeon working in town, but she was trained overseas and imported into our hospital. She was my mentor and ally. She told me stories of her training and gave me valuable insight into the minds of my male colleagues.

When I first started training, I used to get upset about every little thing. She used to shake her head at me and said that I should toughen up, use my stiff upper lip, and basically grow a tough hide. But it wasn’t until she said to me ‘Take it like a Man’ that I realised to succeed and survive my training, I needed to be like my male colleagues. I needed to be one of them.

Behaviour

Short of wearing pants and ties, I started to observe my colleagues. They don’t cry when they get upset (well, maybe only when they were very very drunk), and they tell you as it is when they are. However, when I started to behave like one of the boys, people’s response to me was completely different. When one of my male colleagues started to rant and rave about something that had not been done for his patients, deathly silence ensued, and the nurses scrambled to do his bidding. When I mention that a certain instruction was not followed, nurses shrugged their shoulders at me and I was called a bitch behind my back.

Once, I watched one of my colleagues brush off a female patient’s concern as if it didn’t really matter. The patient reacted by shrugging her shoulders and put it down to ‘he’s a man, he doesn’t understand.’ Yet when I inferred a similar response to her complaint, she carried on about how that I was an unsympathetic doctor and should have been more understanding of her feelings.

So I learnt my lesson. I had to be tough like a male, but I needed to behave like a female, because my co-workers and my patients expected me, as a woman, to be more perceptive to their feeling, to be gentler, thoughtful, considerate and compassionate. All the qualities of their mothers.

Competency

And yet what did people expect of my abilities as a female?

There are several facets to this issue. Firstly, people make assumptions that you understand certain aspects of their lives, or have specific skills because you are female. Patients often tell me that they have specifically chosen me as their surgeon because I am female. That they know I will pay more attention to detail, that my work would be more delicate and that I have gentler hands. I have found these ideas vocalised more from female patients, although the back-handed sexist compliment makes an appearance now and then from the male patients: ‘Female hands are made to do fine embroidery, your sewing would be better.’ This is all inference without evidence. Some of the best microsurgeons I have had the privilege of learning from, are male surgeons with big clumsy-looking hands who couldn’t sew a hem to save their lives.

Some tell me that I would better understand what results they are after because I am female. One of my specialties is cosmetic and reconstructive breast surgery. Even my colleagues have presumptions and send their wives to me as a preference because I would know what beautiful breasts are supposed look like. I have my suspicious that it was more because they hesitate to have one of their male colleagues handling their wives’ bosoms. I often joked with them that beauty is in the eye of the beholder, and unless their wives are lesbians, what I thought would not really matter. Not to mention, as far as I was concerned, you are too big if you are bigger than me. Without fail, their gaze would lower to the A cup push-ups I wore hidden under my dress. The disappointment in their eyes when they come back up to my face is almost comical.

An interesting social survey that was done locally in my state by the Plastic Surgeons’ Society showed that majority of women preferred a male plastic surgeon for cosmetic procedures, but female plastic surgeons for reconstructive procedures (e.g. after cancer surgery, or for treatment of congenital deformities). I guess this may just be a reflection of the underlying reasons for these procedures. Most of the patients who have cosmetic procedures book in because they want to look attractive for the opposite sex, whilst those who have reconstructive procedures proceed for their own self-esteem.

But realistically, are male surgeons better than female surgeons? My personal experience is that overall, the common public perception is that male surgeons are more competent. It is not that unusual for my patients to ask for a second opinion specified to be from a male surgeon. It is also not uncommon that patient find it easier to accept an opinion (especially one that they do not agree with) from a male surgeon. Sometimes I would argue patients until I am blue in the face about my decision, and yet when my male colleague comes to the same conclusion, the answer is a meek ‘Yes, whatever you think is best, doctor.’ It is also not uncommon that when I am doing ward rounds with my junior male residents, the patients look to them to reassurance, assuming that they are the doctors in charge.

This perception is not just restricted to patients. I have had male colleagues who have volunteered to take difficult cases from me because they felt that it was stress I didn’t need or the procedure would be too long for me. I have had to stop myself being a ‘hypersensitive girl’ and ask them if they were questioning my competency; instead, I would often smile sweetly and tell them that ‘you are so thoughtful, but I really enjoy the challenge’. There is also no doubt that my male colleagues are particularly protective of me at times. Once I was bullied by a male colleague from another specialty, because he was not willing to accept that he made a mistake with my patient, an incident which I unfortunately had to bring up at the morbidity and mortality (M&M) meeting. The next thing I knew, two male surgeons from my department cornered the poor man in the tea room two days later. Ever since the incident, that particular surgeon seemed to be awfully fond of stairs when we bump into each other at the hospital lifts. The male protectiveness didn’t just come from senior staff either. When I have had to visit the secure unit (prison hospital) to see some patients with my junior residents, I have had male residents trying to protect me from seeing obnoxious abusive patients. Sweet, but totally unnecessary. I was more effective in getting the prisoners to comply with their therapy than any other surgeon. Apparently a pissed off female surgeon is a lot more terrifying than a male one.

Confidence & Self-Esteem

So with such behaviour surrounding female surgeons, you would think we have no confidence or self-esteem in ourselves. Yes and No. I believe these are two very different things.

Confidence is a projection, or a façade as I’d like to think. This is something a lot of female surgeon learn very quickly early on in their career, because a show of weakness or doubt, especially in front of our male colleagues or senior staff, was a sign we didn’t have what it took to be a good surgeon. Being decisive and making good clinical judgement is the crux of a good surgeon. Several times throughout my career it was emphasised to me that you could teach a monkey to operate, but you could never teach it to choose the right operation. Personally, I don’t think it is hard to project the illusion of confidence, because you see it around you constantly from all your colleagues. I don’t need to puff up my chest or spit at my feet, but when I announce my decision to the team, it is clear to all and sundry that it was my way or the highway.

Self-esteem, however, is another matter. It is no secret that females are more introspective than males. Looking at the gender difference in the psychology of cause and reason – females tend to blame themselves, and males tend to blame external factors. This is no different in surgery. How many times during an M&M have I had to listen to my male colleagues go on and on about how the surgical instruments they were using were old and unreliable, about how the patients were non-compliant, about how the disease was so advanced or that the patient’s anatomy was abnormal. Whereas I hear female surgeons lament about how they should have done this, thought about that, or even not have taken on the challenge in the first place. Whenever an unexpected problem occurs, the female will look inside themselves for reasons rather than recognise that sometimes the patient’s pathology defeats even the best surgeons.

This is something I constantly remind my female trainees (and myself from time to time). I tell them that there has never been any evidence that female surgeons are less competent than male surgeons. Yet, we have an innate inferior complex about ourselves. We tend to beat ourselves up when things go wrong. Then we are tempted to fall in a heap of self-pitying mess. I often tell them that we can’t ignore this female psyche we possess, if anything, it makes us a better surgeon because we are constantly evaluating ourselves. But we have to have the insight to understand that too much of it can be debilitating. Good surgeons should be able to move on from their complications, ‘failures’, and mistakes – to learn from it, and start the next case as a completely fresh problem. We shouldn’t be accumulating ‘baggage’ which erode our self-esteem, because our patients rely on us making the right decisions for them at every crucial moment – and the right decisions are never made when self-doubt takes over the decision making process.

Confidence and self-esteem does go hand in hand. The more self-esteem one possesses, the easier it is to project confidence. However, the biggest trick in the trade is to be able to take criticisms, scrutinies, mistakes and failures on the chin, and yet still project the same confidence so that both your colleagues and your patients will continue to have faith in your abilities. If being a female means you are more critical of yourself, this is not necessarily a bad thing, it just need to be moderated. Having good support from a sympathetic colleagues (male or female) can also go a long way.

Even though surgery is slowly being ‘infiltrated’(as one of my male colleagues like to put it), by females, it is still very much a male-dominant area of medicine; partly due to diminishing remnants of the ‘Old-boys’club’ attitude, but mostly due to its unrelenting hours and commitment. A career in surgery is unconducive for the stereotypical role of women – one of bearing babies, spending time with family, home making and baking cookies. Honestly, the only babies I see are those in the hospital, and the only baking I do is with a diathermy.

So until we have more female surgeons, and society start to see us as the norm, my belief is that we should Take it like a Man, but Give it like a Woman.

While women are generally seen as more warm and caring, men are perceived to be more competent. Unfortunately, these stereotypes are especially pronounced in male dominated fields such as surgery. However, a study by Kamyar Noori and Allyson Weseley gives hope that these stereotypes are slowly changing.

In their experimental study they presented men and women with the profile of either a male or a female physician who was either a surgeon (and thus a member of a male dominated field) or a dermatologist (a member of a female dominated field) and then asked them about their perceptions of warmth, competence and willingness to see the physician. Surprisingly, neither specialty nor gender influenced the perception of competence. Women, even those in a male dominated field, were perceived as just as competent as their male counterparts. Interestingly, the stereotypes around how caring the physicians were perceived to be depended on who was asked: While men rated female physicians as more caring regardless of specialty, women tended to rate those in counter-stereotypical fields (i.e. the female surgeon and the male dermatologist) as more caring.

Overall, this study gives hope that gender stereotypes in medicine may indeed be changing. Go humanity!